Provider Demographics
NPI:1619586708
Name:LONDON, CHARLIE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:LONDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 41ST ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3517
Mailing Address - Country:US
Mailing Address - Phone:631-885-4550
Mailing Address - Fax:
Practice Address - Street 1:33 W 60TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7905
Practice Address - Country:US
Practice Address - Phone:212-333-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY114231104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program